balance billing. 37 In fact, since the ACA only requires plans to pay for emergency services and certain types of preventive care that enrollees receive
from out-of-network providers, claimants may have to pay the entire cost of
out-of-network care themselves. 38 Moreover, more and more out-of-network
physicians and hospitals are unwilling to accept any insurance payments
whatsoever, requiring patients to pay the entire bill out-of-pocket and seek,
on their own, whatever reimbursement they can get from their insurer. 39 The
problem is worsened if patients are unaware that their care is being provided
out-of-network until enormous bills start coming in, and even if made aware,
may be unable to be treated by all in-network providers, especially in a complex hospital stay with multiple providers. 40

The ACA requires HHS to impose network adequacy standards for plans
that are sold on health exchanges.41 The plans must “ensure a sufficient
choice of providers,” include “essential community providers” who serve
low-income, medically-underserved populations, 42 and “maintain[] a network that is sufficient in number and types of providers, including providers
that specialize in mental health and substance abuse services, to assure that
all services will be accessible without unreasonable delay . . . .” 43 As in the
case of the essential benefits package, however, the ACA delegates the responsibility for establishing specific adequacy standards and making sure

37. JACK HOADLEY ET AL., BALANCE BILLING: HOW ARE STATES PROTECTING CONSUMERS
FROM UNEXPECTED CHARGES?, CENTER ON HEALTH INS. REFORMS 3 (June 2015), available at
http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2015/rwjf420966 (defining what
a balance bill is in the article’s introduction).

39. See, e.g., Jen Christensen, Obamacare: Fewer Options For Many, CNN (Oct. 29,
2013, 6:41 PM), http://www.cnn.com/2013/10/29/health/obamacare-doctors-limited/ (
according to CNN, for example, as of 2013, a hospital in Concord, New Hampshire, would not accept
any insurance policies from any health plans from the state’s marketplace, and similar limits
are being imposed by medical centers at New York University, UCLA, and Emory); see also
Sandra L. Decker, In 2011 Nearly One-Third of Physicians Said They Would Not Accept New
Medicaid Patients, But Rising Fees May Help, 31 HEALTH AFF. 1673, 1679 (2012) (citing a
2011 study that found “Thirty-one percent of physicians were unwilling to accept any new
Medicaid patients;; 17% would not accept new Medicare patients; and 18% of physicians
would not accept new privately insured patients.”).

40. See Tara S. Bernard, Out of Network, Not by Choice, and Facing Huge Health Bills,
N. Y. TIMES, Oct. 19, 2013, at B1 (describing a patient’s experience receiving care from out-of-network doctors working in an in-network hospital, not for the hospital, and being charged
higher rates as a result).